A series of successful class action lawsuits have led to positive changes for physicians - in theory. I say in theory because medical billing companies and medical billing departments must be vigilant to make sure that payers are living up to the promises they have made as part of their settlement agreements.
It is critical that quick action be taken each and every time that a settlement agreement is violated. If you believe that Unicare, Humana or BCBS are in violation of their agreement then you need to file a compliance dispute form. Each company requires a different form - of course - but there is no charge for filing a dispute. These forms can be found on the HMO Settlements Web site in the Compliance Center.
This dispute process has teeth and physicians have recovered millions of dollars in previously denied and underpaid claims. In addition, they have also saved millions more by avoiding repaying amounts that payers asserted were overpayments.
An example of the rules by which BCBS has agreed to conduct business will demonstrate how significant the changes have been. As a result of its settlement BCBS:
- May not seek overpayment recovery beyond 18 months (six months for insured plans) unless fraud is implicated;
- Must use a clinically based definition of medical necessity;
- Must adhere to most CPT coding rules, including payment for evaluation and management codes appended with modifier 25 and payment for add-on codes without reduction for Multiple Procedure Logic;
- Must pay for codes submitted with 59 modifiers to the extent they follow CPT rules regarding designation of separate procedures,
- Must provide 90 days advance notice of material adverse changes;
- May not require physicians to participate in all products,
- Must disclose their methodology for determining "usual, customary, and reasonable" amounts.
- Must not utilize global periods for surgical procedures longer than CMS', and
- May not automatically reduce CPT codes to codes of lesser intensity
In order for your practice to fully take advantage of these changes it is critical that you put in place processes to spot violations so that you can pursue the remedies that are proven to work (as described earlier). This is a great opportunity to take advantage of a more level playing field between providers and payers- do not let this pass you by. Make sure that the medical billing service or employee responsible for your medical billing is taking full advantage of these opportunities.
To put this into action you need a systematic process (such as automated reporting) to identify violations by the payers. This process needs to be as automated as possible so that you can catch all violations and not just catch them when they have occurred in volumes o large to miss.
Next you need a process to easily file disputes if a violation has occurred. Again, this must be automated so that it does not always end up at the bottom of the "to do" list. Finally, you need to have a system to follow the disputes to their conclusion.
With these elements in place you can be confident that you are taking full advantage of the agreements that have been made by payers. In addition, you will have a new and powerful weapon in your arsenal to maximize the legitimate collections you are owed for the high value services you provide and the hard work that you perform.
2009 copyright by Carl Mays II and the ClaimCare Medical Billing Company